ACP news

Clinical news in the headlines

Research appears to confirm that early and aggressive treatment of prostate cancer may reduce cancer deaths in men diagnosed in their 60s or younger.

The study, published in the June 9 Journal of the American Medical Association (JAMA), found that low-grade prostate cancers began growing more aggressively after 15 years. Conducted in Sweden, the study tracked 223 men with low-grade prostate cancer for more than 20 years.

Some physicians have preferred to take a watch-and-wait approach because prostate cancer primarily affects older men who could die of other causes before the cancer kills them, according to the June 9 Los Angeles Times. Instead, researchers claimed that men expected to live 15 years or more can benefit from radiation or prostate surgery.

Researchers noted that the study would be difficult to replicate because cancers are treated more aggressively now than when the study began. They said that 60,000 men undergo radical prostatectomy each year in the United States, and there is recent evidence that the procedure reduces mortality by about 50%.

The following articles appear in today's Annals of Internal Medicine. The full text of the issue is available to College members and subscribers online.

Abdominal fat linked to high blood pressure. A study of 300 people with normal blood pressure found that those with larger amounts of fat inside the abdomen were four times more likely to develop hypertension by the end of the 11-year study than those with small or normal amounts. Researchers used a CT scan to measure fat in many locations, such as fat inside the abdomen, fat just under the skin of the abdomen, total body fat and waist size. Only the amount of fat inside the abdomen correlated with the risk for developing hypertension.

Study: Exercise doesn't slow thickening of arteries. In a six-year study of 140 middle-aged white men, a group assigned to regular aerobic exercise improved in fitness but did not have less atherosclerosis than the group that continued its usual physical activity. The aerobic exercise group walked, jogged, skied cross-country, swam or cycled for 45 to 60 minutes five times per week. Artery walls of men in both groups thickened to a similar extent over the study period. However, the artery walls of a subgroup of men in the aerobic exercise group who were not taking statins thickened less than those of men in the usual-exercise group who weren't taking statins.

The business of medicine

In California, the state's largest independent practice association (IPA) has already started paying out pay-for-performance bonuses from health plans to its member physicians, while physician groups throughout the state will receive bonuses later this year from the country's most extensive pay-for-performance plan.

Hill Physicians Medical Group, the state's largest IPA, reported paying out nearly $12 million in bonuses in 2003 to its 2,100 member physicians, reported the June 8 Modern Physician. Of that amount, $5.6 million came from Blue Cross, Blue Shield and Health Net.

Those three plans are also taking part in a six-plan pay-for-performance initiative brokered by the Integrated Healthcare Association (IHA). The plans expect to issue bonus checks to 240 participating physician organizations in the state in September.

The six participating plans—Blue Cross, Blue Shield, Health Net, Aetna, Cigna Healthcare of California and PacifiCare—will calculate bonuses based on the 2003 data according to three criteria: clinical quality (50%), patient satisfaction (40%) and adoption of information technology (10%).

According to Modern Physician, IHA members are considering changing those criteria for 2005 by adding several clinical care measures, dropping the weight of the clinical criteria to 40% of the total bonus, and increasing the weight of the information technology component to 20%.

The annual meeting of the American Society for Clinical Oncology (ASCO), held last week, has become a major event for biotechnology investors as well as for medical researchers. Scientific findings presented at the meeting can have a significant impact on companies' stock prices.

According to the June 7 New York Times, ASCO members in previous years have complained that abstracts of findings to be presented at the meeting have been leaked early to investors, giving some traders an unfair advantage over others.

Last year, society members were not given abstracts before the meeting, leading many to complain that they weren't able to adequately prepare. For this year's meeting, abstracts were sent to members two weeks before the meeting—with a warning to not leak abstract material or use it in investing.

Share of ImClone Systems' stock rose 12% after findings were presented last week that cetuximab (Erbitux) can boost survival time for patients with advance neck and head cancer when combined with radiation, over radiation alone.

However, stock prices for partners Genentech and OSI Pharmaceuticals fell slightly when presented findings for erlotinib (Tarceva) in lung cancer trials, while promising, did not exceed previous forecasts.

In a related story on the ASCO meeting, the June 10 Wall Street Journal reported that record high stock prices for some biotech companies in anticipation of ASCO presentations has produced a "cancer-stock bubble" that may burst.

The Wall Street Journal is online. Text is available only to subscribers.

Screening update

A shortage of radiologists specializing in breast imaging is leading to a serious access problem for many women, according to a new study released last week.

The Institute of Medicine (IOM), which advises the government on health issues, reported that the number of mammography facilities in the country has declined by almost 9% since 2000. Three-month waits for appointments are now standard in parts of Florida, while women in New York City wait an average of 40 days for a first appointment.

The problem stems in part from fewer radiologists specializing in mammography due to low pay, long hours and fear of being sued for malpractice, reported the June 11 Los Angeles Times.

The IOM proposed allowing trained non-physicians to assist in reading mammograms as one way to alleviate access problems. However, the American College of Radiology immediately protested, saying higher reimbursements would be a better solution to increase the number of radiologists and safeguard quality of care.

The report also found that only 60% of women old enough for routine mammograms get the procedure, the Los Angeles Times reported. Factors cited that affect screening include lack of insurance as well as confusion or fear about breast cancer detection.

Each year, 1.2 million more women are eligible for screening mammograms beginning at age 40.

For more information about the shortage of mammography clinics, click here to see "Is an access crisis on the horizon in mammography?"

A major educational campaign is being launched this summer to make patients more aware of risk factors that can lead to kidney disease and to encourage more primary care physicians to screen for the disease in their patients.

The National Kidney Disease Education Program (NKDEP) is being sponsored by the NIH's National Institute of Diabetes and Digestive and Kidney Diseases, the CDC and the American Diabetes Association.

As part of the national campaign, the NKDEP is making tools for physicians available on its Web site including an overview of chronic kidney disease, GFR calculators, kidney disease reference cards and PowerPoint presentations. Physicians can also download patient education brochures.

Kidney disease now affects 20 million Americans, with blacks four times more likely to develop the disease than whites. Diabetes and hypertension are the leading risk factors for the disease, which can be treated with ACE inhibitors and angiotensin II receptor blockers.

FDA news

The FDA recently approved the first diagnostic test that is commercially available for anthrax. According to the June 8 Reuters, results from the new test are available in less than an hour, as compared to four hours with testing previously available.

The new diagnostic test, which was developed with funding from the CDC, detects antibiodies within the blood that are produced during anthrax infection, not just anthrax exposure. While diagnostic testing for anthrax was previously restricted to mainly CDC or military labs, the new test makes it possible to test for anthrax at any commercial laboratory or hospital.

A June 7 CDC press release said the development of the test resulted from a collaboration between the government and private industry. The test will be available soon, the CDC said.

Medical ethics

Physicians are divided on the issue of whether participating in prison executions is helping spare prisoners unnecessary pain or violating core principles of medical ethics.

According to the June 10 New York Times, the issue of physician assistance in executions has become much more prominent now that the majority of condemned prisoners are put to death by lethal injection, not by electrocution or firing squad. The Supreme Court last month found that a condemned prisoner has the right to challenge lethal injection as cruel and unusual punishment and suggested that physician assistance may be required for part of the procedure.

The New York Times reported that 40% of physicians who participated in a 2001 survey said they would be willing to perform at least some of the activities involved in executions by lethal injection, including selecting sites for intravenous drugs, prescribing the drugs and delivering the injections. The alternative is to have non-medical personnel perform those tasks, which can result in prolonged suffering for prisoners.

On the other hand, several medical organizations—including the College—oppose physician assistance in executions. The College's Fourth Edition of the Ethics Manual claims that "participation by physicians in the execution of prisoners except to certify death is unethical." The New York Times quoted one retired psychiatrist who is trying to get sanctions against physicians who participate in lethal injections from professional societies and state medical associations.

Although most state licensing boards have ethical restrictions on participating in executions, the New York Times said, a number of states have passed laws that say assisting in executions is not practicing medicine. Physicians who do provide assistance are therefore not subject to disciplinary action.

ACP news

The College has lent its support to a Senate bill that would provide debt relief for residents specializing in geriatric care.

The Geriatricians Loan Forgiveness Act of 2004 (S. 2075) would count each year of fellowship training in geriatric medicine or geriatric psychiatry as a year of obligated service under the National Health Service Corps Loan Repayment Program.

In a letter sent last month to Senate Majority Leader Bill Frist, ACP President Charles K. Francis, FACP, applauded the effort to encourage physicians to pursue geriatric training by extending loan forgiveness.

The letter noted that by 2030, one-fifth of all Americans will be over age 65, with a growing proportion above age 85. While voicing College support of the bill, Dr. Francis also noted that all internists are trained to care for older patients and that more internists are needed to serve that aging population.

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Copyright 2004 by the American College of Physicians.

Test yourself

A 66-year-old man is evaluated for a persistent rash for 6 years' duration. The rash waxes and wanes in severity, and it becomes pruritic only after he becomes hot and sweating, such as when he mows the lawn or exercises. It has always been limited to his back and lower chest. He has never treated it. The patient is otherwise well, has no other medical problems, and takes no medication. Following a physical exam, what is the most likely diagnosis?

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